The Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada (CWC) are working together to report on patients receiving unnecessary tests and procedures every year in Canada. CIHI is leading a multi-group measurement collaborative to develop methodologies for measuring the rates of selected tests and procedures, which will help ensure that all of CWC's physician recommendations are supported by evidence. By supporting this campaign with comparable, pan-Canadian data on the rates of potentially unnecessary tests and procedures, CIHI and its collaborators are helping to engage patients and their caregivers so that they can make informed choices about their care.
Looking at eightselected CWC recommendations, the Unnecessary Care in Canada report finds that up to 30% of patients had tests, treatments and procedures that were potentially unnecessary.
Read the full report for more details on these lab impacting recommendations:
- Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms
- Don’t perform preoperative testing before low-risk surgeries
Why are the INR results so different, and which result should be used to guide warfarin dosing recommendations?
A 68-year-old female with a history of hypertension, diabetes mellitus, stroke, and atrial fibrillation presents for routine follow-up at your hospital’s anticoagulation clinic. The clinical pharmacist checks her international normalized ratio (INR) with a point-of-care (POC) device to monitor her anticoagulant therapy (warfarin). The POC INR result is elevated to 4.0, which is above the recommended INR goal range of 2.0–3.0 based on her clinical indication of atrial fibrillation. The pharmacist enters the POC INR result into the patient’s electronic medical record and discovers she had an INR obtained earlier that same day, along with a basic metabolic panel and complete blood count ordered by her primary care physician. The clinical lab (CL) INR result was 2.9, and obtained just 90 minutes earlier. All other test results were normal.
The patient says she hasn’t started any new medications or had recent warfarin dose changes, nor has she experienced bleeding symptoms or changed her diet. INR measurements from the past 6 months have all been within range. Given the conflicting INR information, the pharmacist is uncertain whether the patient should continue her current warfarin dosing schedule or have an adjustment.
Read the full article to understand some of the benefits and limitations associated with POC INR testing as well as the discordance between POC and CL INR assays, as well as suggested strategies for managing discordant INR values.